Telehealth

Coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, pharmacologic management and other services delivered via an interactive audio and video telecommunications system. Providers are located at the distant site and beneficiaries are located at the originating site.

View the below related information on this page.

Distant Site

The distant site is where the physician or non-physician practitioner (NPP) is located and provides services using an interactive audio and video telecommunication system that permits real-time communication with the beneficiary. The location must be on the provider's enrollment file. For example, if the provider uses their home as an office location, the home must be listed on the enrollment file. A hotel, boat and car are not valid locations. The provider must be licensed and enrolled in the state the services are provided in. For example, if a beneficiary is in California and the provider is in Florida, the provider must be licensed and enrolled with the Medicare Administrative Contractor (MAC) for Florida.

Distant site practitioners (subject to State law) are:

  • Physicians
  • Nurse practitioners (NP)
  • Physician assistants (PA)
  • Nurse-midwives
  • Clinical nurse specialists (CNSs)
  • Certified registered nurse anesthetists
  • Clinical psychologist (CP) and clinical social workers (CSWs)
  • Registered dietitians or nutrition professionals

A medical professional is not required to present the beneficiary to the physician or practitioner unless it is medically necessary. The decision of medical necessity is made by the physician or practitioner at the distant site.

Originating Site

Beneficiaries are eligible for telehealth services only if they are treated at an originating site located either in a rural health professional shortage areas (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA). The Health Resources and Services Administration (HRSA) provides a tool to determine the originating site's eligibility. The originating site fees are billed by Part A providers.

Originating sites authorized by law are:

  • Office of physicians or practitioners
  • Hospitals
  • Critical Access Hospitals (CAHs)
  • Rural Health Clinics (RHCs)
  • Federally Qualified Health Centers (FQHCs)
  • Hospital-based or CAH-based Renal Dialysis Centers
  • Skilled Nursing Facilities (SNF)
  • Community Mental Health Centers

If the above statutory requirements for the originating site are not met, the claim for both the originating site and distant site must be submitted with modifier GY. The beneficiary's home is not a covered originating site.

The originating site may be paid an originating site fee, HCPCS Q3014.

Eligible Services

The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services and a limited number of other physician services if the beneficiary is present and participating. These services are listed below.

CPT/HCPCS Code Description
90785 Interactive complexity for diagnostic psychiatric evaluation
90791 and 90792 Psychiatric diagnostic interview examination
90832, 90833, 90834, 90836, 90837, 90838 Individual psychotherapy
90839, 90840 Psychotherapy for crisis
90845 Psychoanalysis
90846, 90847 Family psychotherapy
90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970 End Stage Renal Disease (ESRD) related services
96116 Neurobehavioral status exam
96150, 96151, 96152, 96153, 96154 Individual and group health and behavior assessment and intervention (HBAI)
96160, 96161 Health risk assessment
97802, 97803, 97804 Medical Nutrition Therapy (MNT)
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215 Office or other outpatient Evaluation and Management (E/M) visits
99231, 99232, 99233 Subsequent hospital care services (with the limitation of one telehealth visit every three days)
99307, 99308, 99309, 99310 Subsequent nursing facility care services (with the limitation of one telehealth visit every 30 days)
99354, 99355, 99356, 99357 Prolonged E/M visits
99406, 99407 Smoking cessation services
99495, 99496 Transitional care management (TCM) services
99497, 99498 Advanced care planning (ACP)
G0108, G0109 Individual and group Diabetes Self-Management Training (DSMT) services (with a minimum of one hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training)
G0270 MNT reassessment and subsequent interventions for change in diagnosis
G0296 Visit to determine Low Dose Computed Tomography (LDCT) eligibility
G0396, G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services
G0406, G0407, G0408 Follow-up inpatient telehealth consultations
G0420, G0421 Individual and group kidney disease education (KDE) services
G0425, G0426, G0427 Telehealth consultations, emergency department or initial inpatient
G0436, G0437 Tobacco-use counsel
G0438, G0439 Annual Wellness Visit (AWV)
G0442 Annual alcohol misuse screening
G0443 Brief face-to-face behavioral counseling for alcohol misuse
G0444 Annual depression screening
G0445 High-intensity behavioral counseling to prevent sexually transmitted infections
G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease
G0447 Face-to-face behavioral counseling for obesity
G0459 Pharmacologic management
G0506 Extended care planning for Chronic Care Management (CCM)
G0508, G0509 Critical care telehealth consultation

 

Additional information regarding inpatient hospital, emergency department and follow-up consultations, ESRD-related services, subsequent hospital care and subsequent nursing facility visits and Diabetes Self-Management Training (DSMT) is available in the CMS Internet Only Manual (IOM), Publication 100-04, Chapter 12.

Acceptable Equipment

Common Skype is not acceptable for telehealth purposes; however, professional Skype-like products are available. Health Insurance Portability and Accountability Act (HIPAA) guidelines require that any software transmitting protected personal health information meet a 128-bit level of encryption, at a minimum, need auditing, archival and backup capabilities. State laws must also be followed.

Billing

Modifier
  • For services furnished prior to January 1, 2018, modifier GT must be billed to indicate beneficiary was present at an eligible originating site when service was furnished. Modifier GT is not required on services furnished and billed to Part B after January 1, 2018
  • Regardless of date of service, when billing modifier GT with covered ESRD services, it indicates that one "hands on" visit per month was furnished to examine vascular access site
  • Modifier GT is still required on distant site services billed under Critical Access Hospital (CAH) Method II on institutional claims
  • CMS has not yet instructed Medicare to use modifier 95
Place of Service
  • To indicate telehealth service from a distant site, claim must be billed with place of service 02: Telehealth
  • Distant site and originating site cannot be same location

 

Federal Demonstration Project

In Alaska and Hawaii only, federal demonstration project allows the following differences:

  • Use of asynchronous "store and forward" technology is allowed
  • Providers must bill modifier GQ with distant site code. This indicates asynchronous medical file was collected and transmitted to provider at distant site
  • Geographic location can be anywhere; rural HPSA or non-MSA does not apply

Resources

Last Updated Jul 19, 2018

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.